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Potential Liability Incident Report TC-2 - Nevada

Potential Liability Incident Report Form. This is a Nevada form and can be used in Office Of Attorney General Statewide .
 Fillable pdf Last Modified 6/9/2005
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AG Office use ONLY: Date TC-1 sent ________ State of Nevada Potential Liability Incident Report INSTRUCTIONS: Agency should use this form to report potential liability claims against the State. Original of this Incident Report should be sent ASAP to: Claims Manager, Office of the Attorney General, 100 North Carson Street, Carson City NV 89701-4717 If an individual wishes to make a formal claim against the State, the individual should notify the Office of the Attorney General at TEL: 775/684-1263; FAX. 775/684-1275. The Attorney Generals Office will send the appropriate form to the injured/damaged party. PLEASE NOTE: Do not use this form to report injuries of State employees; a Workers Compensation injury report must be filed in those instances. Please type or print clearly Name of Inured/Damaged Party: Mailing Address: Telephone No. Date of Incident: Time: Location where incident occurred (include street address): Department: Division: Budget Account: Contact Person: Title: Telephone No.: Please provide a detailed description of what happened & attach all supporting documentation you may have. (Attach additional pages if necessary): Form completed by: Date: TC-2 (revision of RSK-002, 6/04) Office of the Attorney General
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